Methods and compositions for treating urinary incontinence using enantiomerically enriched (S,S)-glycopyrrolate

ABSTRACT

A method for treating urinary incontinence, such as incontinence resulting from bladder detrusor muscle instability, using enantiomerically enriched (S,S)-glycopyrrolate. The method comprises administering a therapeutically effective amount of enantiomerically enriched (S,S)-glycopyrrolate, or a pharmaceutically acceptable salt thereof, substantially free of the (R,R)-glycopyrrolate enantiomer. Pharmaceutical compositions for the treatment of urinary incontinence comprising enantiomerically enriched (S,S)-glycopyrrolate, or a pharmaceutically acceptable salt thereof, and an acceptable carrier are also disclosed.

CROSS REFERENCE TO REALTED APPLICATIONS

This application is the United States National Phase of InternationalPatent Application PCT/US97/11645, filed Jun. 27, 1997, and claims thepriority of U.S. Provisional Patent Application Serial No. 60/021,020,filed Jul. 1, 1996, the entire contents of each is hereby incorporatedby reference.

FIELD OF THE INVENTION

The present invention relates to methods for treating urinaryincontinence, such as incontinence caused by bladder detrusor muscleinstability, and to pharmaceutical compositions for such treatment.

BACKGROUND OF THE INVENTION

Urinary incontinence is a prevalent problem that affects people of allages and levels of physical health, both in healthcare settings and inthe community at large. At present, urinary incontinence afflicts 15-30%of elderly people living at home, one-third of those living inacute-care settings, and at least one-half of those in long-term careinstitutions (R. M. Resnick, Lancet 346:94 (1995)). Medically, itpredisposes persons to urinary tract infections, pressure ulcers,perineal rashes, and urosepsis. Psychosocially, urinary incontinence isassociated with embarrassment, social stigmatization, depression, andwith the risk of institutionalization (Herzo et al., Annu. Rev.Gerontol. Geriatr., 9:74 (1989)). Economically, the costs are great; inthe United States alone, over $10 billion is spent per annum managingincontinence.

Treatments for incontinence include drugs with bladder relaxantproperties, i.e., which help to control bladder detrusor muscleoveractivity. Such drugs are effective in 80 to 85% of patients withuninhibited bladder contractions, with anticholinergic medicationsrepresenting the mainstay of this type of treatment. For example,anticholinergics such as propantheline bromide, and combination smoothmuscle relaxant/anticholinergics such as racemic oxybutynin anddicyclomine, have been used to treat urge incontinence. (See, e.g., A.J. Wein, Urol. Clin. N. Am., 22:557-77 (1995).)

Another anticholinergic drug, glycopyrrolate,3-[(Cyclopentylhydroxyphenylacetyl)oxy]-1,1-dimethylpyrrolidiniumbromide, has also been described for use in the treatment ofincontinence (Levin et al., J. Urol., 128:396-398 (1982); Cooke et al.,S. Afr. Med. J., 63:3 (1983); R. K. Mirakhur and J. W. Dundee,Anaesthesia, 38:1195-1204 (1983)). Glycopyrrolate has two centers ofasymmetry (chiral centers), and can exist in four stereoisometric forms,i.e., two enantiomeric pairs of diastereomers. The two diastereomerpairs have been separated from one another (see, e.g., Demian et al., J.Liq. Chromatog., 13:779-787 (1990)). However, separation of thediastereomers to their individual enantiomers has not been reported, andcommercially available formulations of glycopyrrolate (e.g., Robinul®, aproduct of A. H. Robins) contain both the (R,S)-glycopyrrolate and(S,R)-glycopyrrolate enantiomers.

No treatment for incontinence, including existing drug therapies, hasachieved complete success with all classes of incontinent patients, andwithout significant side effects. For example, adverse effects, such asdrowsiness, dry mouth, constipation, blurred vision, headaches, andcardiac arrhythmia which are related to the anticholinergic activity ofdrugs such as racemic oxybutynin, occur frequently and can besufficiently troublesome to necessitate discontinuing treatment in up to25% of patients, depending on the dosage. Yet, despite the occurrence ofunwanted anticholinergic effects in many patients, and an apparent lackof efficacy in the elderly institutionalized population, racemicoxybutynin nevertheless is considered the drug of first choice inpatients with bladder detrusor muscle hyperactivity when pharmacologicaltherapy is indicated (cf. Yarllur et al., Drugs Aging, 6:243 (1995)).Similar side effects resulting from the use of glycopyrrolate are alsodescribed in the literature. (Cf. Physician's Desk Reference, 50thEdition, pages 2072-2073 (1996).)

SUMMARY OF THE INVENTION

The present invention provides methods and compositions for treatment ofurinary incontinence, including, e.g., bladder detrusor muscleinstability incontinence, stress incontinence, urge incontinence,overflow incontinence, enuresis, and post-prostectomy incontinence, with(S,S)-glycopyrrolate. The methods of the present invention provide fortreatment of incontinence with fewer adverse effects than occur uponadministration of racemic glycopyrrolate.

One aspect of the present invention relates to methods for treatingurinary incontinence by administration to a subject in need thereof atherapeutically effective amount of enantiomerically enriched(S,S)-glycopyrrolate, or a pharmaceutically acceptable salt thereof. Ina preferred embodiment of this method, the enantiomerically enriched(S,S)-glycopyrrolate, or a pharmaceutically acceptable salt thereof, issubstantially free of (R,R)-glycopyrrolate.

The present invention also relates to methods for treating bladderdetrusor muscle instability comprising administration to a subject inneed thereof a therapeutically effective amount of enantiomericallyenriched (S,S)-glycopyrrolate, or a pharmaceutically acceptable saltthereof. Preferably, the enantiomerically enriched (S,S)-glycopyrrolate,or a pharmaceutically acceptable salt thereof, is substantially free of(R,R)-glycopyrrolate.

Another aspect of the present invention relates to pharmaceuticalcompositions for the treatment of urinary incontinence comprisingenantiomerically enriched (S,S)-glycopyrrolate, or a pharmaceuticallyacceptable salt thereof, and a pharmaceutically acceptable carrier. In apreferred embodiment, the pharmaceutical compositions of the presentinvention comprise (S,S)-glycopyrrolate, or a pharmaceuticallyacceptable salt thereof, substantially free of (R,R)-glycopyrrolate.

The present invention also provides for formulating the pharmaceuticalcompositions of the present invention, comprising enantiomericallyenriched (S,S)-glycopyrrolate, or a pharmaceutically acceptable saltthereof, and a pharmaceutically acceptable carrier, in pharmaceuticalunit dosage forms, including, e.g., tablets and soft elastic gelatincapsules.

Yet another embodiment of the present invention relates to a kit fortreating urinary incontinence, such as bladder detrusor muscleinstability incontinence, stress incontinence, urge incontinence,overflow incontinence, enuresis, and post-prostectomy incontinence,wherein said kit comprises a pharmaceutical composition comprisingenantiomerically enriched (S,S)-glycopyrrolate, or a pharmaceuticallyacceptable salt thereof, and a pharmaceutically acceptable carrier, andinstructions for administering the same while reducing or eliminatinganticholinergic adverse effects associated with administration ofracemic glycopyrrolate, or other incontinence drugs with anticholinergicaction. Preferably, the enantiomerically enriched (S,S)-glycopyrrolate,or a pharmaceutically acceptable salt thereof, is substantially free of(R,R)-glycopyrrolate.

DETAILED DESCRIPTION OF THE INVENTION

It is known that urinary incontinence can be caused by uncontrolled orunstable bladder contractions, particularly of the bladder detrusormuscle which serves to force fluids out of the bladder. The majorproportion of the neurohumeral stimulus for physiologic bladdercontraction is acetylcholine-induced stimulation of postganglionicmuscarinic receptor sites on bladder smooth muscle. Consistent with thisobservation, most pharmacologic treatments for incontinence associatedwith uninhibited bladder contractions include medications withanticholinergic and smooth muscle relaxant properties. However, as setout above, many of the anticholinergic agents which have been used forthe treatment of incontinence often have adverse effects associated withtheir anticholinergic actions, which result in at least periodicdiscontinuation of use in a significant portion of the treatedpopulation.

The present invention relates to compositions and methods for thetreatment of bladder instability in mammals, such as humans. Morespecifically, this invention provides enantiomerically enrichedpreparations of (S,S)-glycopyrrolate and methods for their use in thetreatment of urinary incontinence, including, e.g., bladder detrusormuscle instability incontinence, stress incontinence, urge incontinence,overflow incontinence, enuresis, and post-prostectomy incontinence. Onefeature of the subject non-racemic preparations of (S,S)-glycopyrrolatederives from the enantiomer's pharmacological advantage over theracemate in terms of its principal therapeutic and side effect profile.Certain deleterious local and/or systemic adverse effects of the racemicmixture, e.g., drowsiness, xerostomia, mydriasis, constipation,cycloplegia, cardiac arrhythmia and/or epistaxis may be reduced oreliminated through treatment with enantiomerically enriched(S,S)-glycopyrrolate.

The chemical structure of (S,S)-glycopyrrolate is as set forth inFormula I: ##STR1## In (S,S)-glycopyrrolate, the first chiral centerdesignated refers to the configuration of the benzylic chiral center,and the second refers to the configuration of the pyrrolidinium chiralcenter.

In one aspect, the present invention provides a method for treatingurinary incontinence using (S,S)-glycopyrrolate, which results in areduction of the adverse effects associated with administration ofracemic glycopyrrolate. The method comprises administering to a patientin need thereof a pharmaceutically effective amount of(S,S)-glycopyrrolate, or a pharmaceutically acceptable salt thereof,substantially free of (R,R)-glycopyrrolate. In a preferred embodiment,the methods of the present invention are used to treat urinaryincontinence due to bladder detrusor muscle instability. Suchinstability may result in, for example, stress incontinence or urgeincontinence, or combination thereof, and/or enuresis.

In another aspect, the present invention provides pharmaceuticalcompositions which comprise an enantiomerically enriched preparation of(S,S)-glycopyrrolate, or a pharmaceutically acceptable salt thereof,formulated together with one or more pharmaceutically acceptablecarriers (additives) and/or diluents. As described in detail below, thepharmaceutical compositions of the present invention may be speciallyformulated for administration in solid or liquid form, including thoseadapted for oral administration, parenteral administration, or topicalapplication.

For convenience, certain terms employed in the specification, examples,and appended claims are collected here.

The term "chiral" refers to molecules which have the property ofnon-superimposability of the mirror image partner, while the term"achiral" refers to molecules which are superimposable on their mirrorimage partner.

The term "stereoisomers" refers to compounds which have identicalchemical constitution, but differ with regard to the arrangement of theatoms or groups in space. In particular, "enantiomers" refer to twostereoisomers of a compound which are non-superimposable mirror imagesof one another. "Diastereomers", on the other hand, refers tostereoisomers with two or more centers of dissymmetry and whosemolecules are not mirror images of one another. With respect to thenomenclature of a chiral center, the terms "S" and "R" configuration areas defined by the IUPAC 1974 Recommendations for Section E., FundamentalStereochemistry, Pure Appl. Chem., 45:13-30 (1976). The termsdiastereomer, racemate and enantiomer will be used in their normalcontext to describe the stereochemistry of glycopyrrolate preparations.

As used herein, the term "diastereomerically enriched" means acomposition which is enriched in one diastereomer, or pair ofdiastereomers, compared to a control mixture of diastereomers. Forexample, a preparation containing only one or both of(S,S)-glycopyrrolate and (R,R)-glycopyrrolate is said to bediastereomerically enriched compared to a composition containing the(R,S)-glycopyrrolate and (S,R)-glycopyrrolate diastereomers in additionto the (S,S)-glycopyrrolate and (R,R)-glycopyrrolate diastereomer(s).

Similarly, the terms "enantiomerically enriched" and "non-racemic", asused interchangeably herein with reference to preparations ofglycopyrrolate, refer to diastereomerically enriched glycopyrrolatecompositions in which the (S,S)-glycopyrrolate enantiomer is enriched,compared to a control mixture of (S,S)-glycopyrrolate and(R,R)-glycopyrrolate enantiomers. Unless otherwise specified, such termsrefer to glycopyrrolate compositions in which the ratio of(S,S)-glycopyrrolate to (R,R)-glycopyrrolate enantiomers is greater than1:1 by weight. For instance, an enantiomerically enriched preparation of(S,S)-glycopyrrolate, means a preparation of glycopyrrolate havinggreater than 50% by weight of the (S,S)-glycopyrrolate enantiomerrelative to the (R,R)-glycopyrrolate enantiomer, more preferably atleast 75% by weight, and even more preferably at least 80% by weight. Ofcourse, the enrichment can be much greater than 80% by weight, providinga "substantially enantiomerically enriched" or a "substantiallynon-racemic" preparation, which refers to preparations of glycopyrrolatewhich have at least 85% by weight of the (S,S)-glycopyrrolate enantiomerrelative to the (R,R)-glycopyrrolate enantiomer, more preferably atleast 90% by weight, and even more preferably at least 95% by weight.The term "substantially free of (R,R)-glycopyrrolate" will be understoodto have similar purity ranges., i.e., at least 85% by weight of the(S,S)-glycopyrrolate enantiomer relative to the (R,R)-glycopyrrolateenantiomer, more preferably at least 90% by weight, and even morepreferably at least 95% by weight.

The term "adverse effects" as used herein, refers to effects associatedwith administration of racemic glycopyrrolate, which are not part of thedesired therapeutic effect of the drug. With respect to the treatment ofurinary incontinence, such adverse effects, include, for illustrativepurposes, drowsiness, epistaxis, xerostomia, mydriasis, cycloplegia,unstable cardiovascular status such as arrhythmia (e.g., tachycardia orpalpitations), increased ocular pressure, nausea, constipation,decreased sweating, impotence, and/or dermal manifestations such asurticaria.

The term "epistaxis" refers to nosebleeds, e.g., hemorrhage from thenose. Epistaxis is a side effect of anticholinergics in children.

The term "xerostomia" refers to dryness of the mouth due to lack ofnormal secretion.

The term "mydriasis" refers to dilation of the pupil, and often resultsin blurred vision.

The term "cycloplegia" refers to paralysis of the ciliary muscle;paralysis of accommodation.

The term "enuresis" refers to the involuntary discharge of urine, and"nocturnal enuresis" refers to involuntary discharge of urine duringsleep at night.

Separation of enantiomers can be accomplished in several ways known inthe art. For example, a racemic mixture of two enantiomers can beseparated by chromatography using a chiral stationary phase (see, e.g.,"Chiral Liquid Chromatography", W. J. Lough, Ed. Chapman and Hall, NewYork (1989)). Enantiomers can also be separated by classical resolutiontechniques. For example, formation of diastereometric salts andfractional crystallization can be used to separate enantiomers. For theseparation of enantiomers of carboxylic acids, the diastereometric saltscan be formed by addition of enantiomerically pure chiral bases such asbrucine, quinine, ephedrine, strychnine, and the like. Alternatively,diastereometric esters can be formed with enantiomerically pure chiralalcohols such as menthol, followed by separation of the diastereomericesters and hydrolysis to yield the free, enantiomerically enrichedcarboxylic acid. For separation of the optical isomers of aminocompounds, addition of chiral carboxylic or sulfonic acids, such ascamphorsulfonic acid, tartaric acid, mandelic acid, or lactic acid canresult in formation of the diastereomeric salts.

In addition to separation techniques such as those described above, theactive enantiomer of glycopyrrolate can be synthesized by stereospecificsynthesis to produce only the desired optical isomer using methodologywell known to those skilled in the art. Chiral synthesis can result inproducts of high enantiomeric purity. However, in some cases, theenantiomeric purity of the product is not sufficiently high. The skilledartisan will appreciate that the separation methods described above canbe used to further enhance the enantiomeric purity of glycopyrrolateobtained by chiral synthesis.

The optical purity of the (S,S)-glycopyrrolate can be determined bymethods known in the art. For example, a sample of the glycopyrrolatecan be analyzed by high performance liquid chromatography on a chiralchromatographic column. Another method of determining optical purityinvolves making a chiral ester, such as a Mosher ester, of aglycopyrrolate sample, and analyzing the NMR spectrum for the presenceof the undesired enantiomer.

In preferred embodiments, (S,S)-glycopyrrolate is substantially free of(R,R)-glycopyrrolate. "Substantially free" as used herein, means that atleast 85% by weight of the total glycopyrrolate present is the(S,S)-glycopyrrolate enantiomer; more preferably at least 90% by weight,and still more preferably at least 95% by weight is the(S,S)-glycopyrrolate enantiomer. In a more preferred embodiment, atleast 99% by weight of the total glycopyrrolate present is the(S,S)-glycopyrrolate enantiomer. Furthermore, (S,S)-glycopyrrolate ispreferably free of the undesired (R,S)-glycopyrrolate and(S,R)-glycopyrrolate diastereomers, which can be readily separated from(S,S)-glycopyrrolate and (R,R)-glycopyrrolate as is known in the art.

(S,S)-glycopyrrolate can be used to treat urinary incontinence,including, e.g., bladder detrusor muscle instability incontinence,stress incontinence, urge incontinence, overflow incontinence, enuresis,and post-prostectomy incontinence, by administration to a patientaccording to any suitable route of administration. (See, Remington:TheScience and Practice of Pharmacy, Nineteenth Edition, Chapters 83-95(1995).) For example, a preferred method of administration is oraladministration. Another preferred route of administration is intravenousadministration. A particularly preferred route of administration isintravesical delivery, i.e., administration directly to the bladder,e.g., by injection or infusion.

According to the present invention, (S,S)-glycopyrrolate is preferablyadministered as a pharmaceutical formulation (composition). The phrase"pharmaceutically acceptable" is employed herein to refer to thosecompounds, materials, compositions, and/or dosage forms which are,within the scope of sound medical judgment, suitable for use in contactwith the tissues of human beings and animals without excessive toxicity,irritation, allergic response, or other problem or complication,commensurate with a reasonable benefit/risk ratio.

As set out above, (S,S)-glycopyrrolate contains a quaternary aminofunctional group, and thus is capable of forming pharmaceuticallyacceptable salts. The term "pharmaceutically acceptable salts" in thisrespect, refers to the relatively non-toxic, inorganic and organic saltsof (S,S)-glycopyrrolate. These salts can be prepared in situ during thefinal isolation and purification of the (S,S)-glycopyrrolate.Representative salts include the bromide, chloride, hydrobromide,hydrochloride, sulfate, bisulfate, phosphate, nitrate, acetate,valerate, oleate, palmitate, stearate, laurate, benxoate, lactate,phosphate, tosylate, citrate, maleate, fumarate, succinate, tartrate,naphthylate, mesylate, glucoheptonate, lactobionate, and laurylsulfonatesalts and the like. (See, e.g., Berge et al., "Pharmaceutical Salts", J.Pharm. Sci., 66:1-19 (1977).)

Formulations of the present invention include those suitable for oral,nasal, topical (including buccal and sublingual), rectal, vaginal and/orparenteral administration. The formulations may conveniently bepresented in unit dosage form and may be prepared by any methods wellknown in the art of pharmacy. The amount of active ingredient which iscombined with a carrier material to produce a single dosage form willvary depending upon the host being treated, and the particular mode ofadministration. The amount of active ingredient which may be combinedwith a carrier material to produce a single dosage form preferably willbe that amount of (S,S)-glycopyrrolate which produces a therapeuticeffect. Generally, the amount of the active ingredient will range fromabout 1% to about 99% of the total formulation, preferably from about 5%to about 70%, and most preferably from about 10% to about 30%.

Methods of preparing these formulations or compositions include the stepof bringing into association (S,S)-glycopyrrolate with apharmaceutically acceptable carrier and, optionally, one or moreaccessory ingredients. In general, the formulations are prepared byuniformly and intimately bringing into association (S,S)-glycopyrrolatewith liquid carriers, or finely divided solid carriers, or both, and anyoptional accessory ingredients, and then, if necessary, shaping theproduct.

The phrase "pharmaceutically acceptable carrier" as used herein means apharmaceutically acceptable material, composition or vehicle, such as aliquid or solid filler, diluent, excipient, solvent or encapsulatingmaterial, involved in carrying or transporting the (S,S)-glycopyrrolatefrom one organ, or portion of the body, to another organ or portion ofthe body. Each carrier must be "acceptable" in the sense of beingcompatible with the other ingredients of the formulation and notinjurious to the patient.

Some examples of materials which can serve as pharmaceuticallyacceptable carriers include: (1) sugars, such as lactose, glucose andsucrose; (2) starches, such as corn starch and potato starch; (3)cellulose, and its derivatives, such as sodium carboxymethyl cellulose,ethyl cellulose and cellulose acetate; (4) powdered tragacanth; (5)malt; (6) gelatin; (7) talc; (8) excipients, such as cocoa butter andsuppository waxes; (9) oils, such as peanut oil, cottonseed oil,safflower oil, sesame oil, olive oil, corn oil and soybean oil; (10)glycols, such as propylene glycol; (11) polyols, such as glycerin,sorbitol, mannitol and polyethylene glycol; (12) esters, such as ethyloleate and ethyl laurate; (13) agar; (14) buffering agents, such asmagnesium hydroxide and aluminum hydroxide; (15) alginic acid; (16)pyrogen-free water; (17) isotonic saline; (18) Ringer's solution; (19)ethyl alcohol; (20) phosphate buffer solutions; and (21) other non-toxiccompatible substances employed in pharmaceutical formulations (see,Remington: The Science and Practice of Pharmacy, Nineteenth Edition,Chapter 80 (1995).)

Formulations of the present invention suitable for oral administrationmay be in the form of capsules, cachets, pills, tablets, lozenges (usinga flavored basis, usually sucrose and acacia or tragacanth), powders,granules, or as a solution or a suspension in an aqueous or non-aqueousliquid, or as an oil-in-water or water-in-oil liquid emulsion, or as anelixir or syrup, or as pastilles (using an inert base, such as a gelatinand glycerin, or sucrose and acacia), or as soft elastic gelatincapsules, and/or as mouth washes and the like, each containing apredetermined amount of a compound of the present invention as an activeingredient. (S,S)-glycopyrrolate may also be administered as a bolus,electuary or paste.

In solid dosage forms of the present invention for oral administration(capsules, tablets, pills, dragees, powders, granules and the like), theactive ingredient is mixed with one or more pharmaceutically acceptablecarriers, such as sodium citrate or dicalcium phosphate, and/or may alsobe mixed with one or more of any of the following: (1) fillers orextenders, such as starches, lactose, sucrose, glucose, mannitol, and/orsilicic acid; (2) binders, such as, for example, carboxymethylcellulose,alginates, gelatin, polyvinyl pyrrolidone, sucrose and/or acacia; (3)humectants, such as glycerol; (4) disintegrating agents, such asagar-agar, calcium carbonate, potato or tapioca starch, alginic acid,certain silicates, and sodium carbonate; (5) solution retarding agents,such as paraffin; (6) absorption accelerators, such as quaternaryammonium compounds; (7) wetting agents, such as, for example, cetylalcohol and glycerol monostearate; (8) absorbents, such as kaolin andbentonite clay; (9) lubricants, such as talc, calcium stearate,magnesium stearate, solid polyethylene glycols, sodium lauryl sulfate,and mixtures thereof; and (10) coloring agents. In the case of capsules,tablets and pills, the pharmaceutical compositions may also comprisebuffering agents. Solid compositions of a similar type may also beemployed as fillers in soft and hard-filled gelatin capsules using suchexcipients as lactose or milk sugars, as well as high molecular weightpolyethylene glycols and the like.

Release agents, coating agents, sweetening, flavoring and perfumingagents, preservatives and antioxidants can also be present in thecompositions of the present invention. Examples of pharmaceuticallyacceptable antioxidants include: (1) water soluble antioxidants, such asascorbic acid, cysteine hydrochloride, sodium bisulfate, sodiummetabisulfate sodium sulfite and the like; (2) oil-soluble antioxidants,such as ascorbyl palmitate, butylated hydroxyanisole (BHA), butylatedhydroxytoluene (BHT), lecithin, propyl gallate, alpha-tocopherol, andthe like; and (3) metal chelating agents, such as citric acid,ethylenediamine tetraacetic acid (EDTA), sorbitol, tartaric acid,phosphoric acid, and the like.

A tablet may be made by compression or molding, optionally with one ormore accessory ingredients. Compressed tablets may be prepared usingbinder (for example, gelatin or hydroxypropylmethyl cellulose),lubricant, inert diluent, preservative, disintegrant (for example,sodium starch glycolate or cross-linked sodium carboxymethyl cellulose),and/or surface-active or dispersing agents. Molded tablets may be madeby molding in a suitable machine a mixture of the powdered(S,S)-glycopyrrolate moistened with an inert, liquid diluent.

The pharmaceutical compositions of the present invention may also beformulated in a soft elastic gelatin capsule unit dosage form by usingconventional methods, well-known in the art (see, e.g., Ebert, Pharm.Tech., 1(5):44-50(1977)). Soft elastic gelatin capsules have a soft,globular, gelatin shell somewhat thicker than that of hard gelatincapsules, wherein a gelatin is plasticized by the addition of glycerin,sorbitol, or a similar polyol. The hardness of the capsule shell may bechanged by varying the type of gelatin and the amounts of plasticizerand water. The soft gelatin shells may contain a preservative to preventthe growth of fungi, such as methyl- and propylparabens and sorbic acid.The active ingredient may be dissolved or suspended in a liquid vehicleor carrier, such as vegetable or mineral oils, glycols such aspolyethylene glycol and propylene glycol, triglycerides, surfactantssuch as polysorbates, or a combination thereof.

The tablets, and other dosage forms of the pharmaceutical compositionsof the present invention, such as dragees, capsules, pills and granules,may optionally be scored or prepared with coatings and shells, such asenteric coatings and other coatings well known in the pharmaceuticalformulating art.

The pharmaceutical compositions of the present invention may also beformulated so as to provide slow or controlled release of the activeingredient therein using, for example, hydroxypropylmethyl cellulose invarying proportions to provide the desired release profile, otherpolymer matrices, liposomes and/or microspheres. They may also beadministered by controlled release means and delivery devices such asthose in U.S. Pat. Nos. 3,845,770; 3,916,899; 3,536,809; 3,598,123; and4,008,796; and PCT published application WO 92/20377.

The pharmaceutical compositions of the present invention may alsooptionally contain opacifying agents and may be formulated such thatthey release the active ingredient(s) only, or preferentially, in acertain portion of the gastrointestinal tract, optionally, in a delayedmanner. Examples of embedding compositions which can be used includepolymeric substances and waxes. The active ingredient can also be inmicro-encapsulated form, if appropriate, with one or more of theabove-described excipients.

Liquid dosage forms for oral administration of (S,S)-glycopyrrolateinclude pharmaceutically acceptable emulsions, microemulsions,solutions, suspensions, syrups and elixirs. In addition to the activeingredient, the liquid dosage forms may contain inert diluents commonlyused in the art, such as, for example, water or other solvents,solubilizing agents and emulsifiers, such as ethyl alcohol, isopropylalcohol, ethyl carbonate, ethyl acetate, benzyl alcohol, benzylbenzoate, propylene glycol, 1,3-butylene glycol, oils (in particular,cottonseed, groundnut, corn, germ, olive, castor and sesame oils),glycerol, tetrahydrofuryl alcohol, polyethylene glycols and fatty acidesters of sorbitan, and mixtures thereof.

Besides inert diluents, the oral compositions of the present inventioncan also include adjuvants such as wetting agents, emulsifying andsuspending agents, sweetening, flavoring, coloring, perfuming andpreservative agents.

Suspensions, in addition to the active (S,S)-glycopyrrolate, may containsuspending agents such as, for example, ethoxylated isostearyl alcohols,polyoxyethylene sorbitol and sorbitan esters, microcrystallinecellulose, aluminum metahydroxide, bentonite, agar-agar and tragacanth,and mixtures thereof.

Formulations of the pharmaceutical compositions of the present inventionfor rectal and vaginal administration may be presented as a suppository,which may be prepared by mixing one or more compounds of the inventionwith one or more suitable non-irritating excipients or carrierscomprising, for example, cocoa butter, polyethylene glycol, asuppository wax or a salicylate. Such formulations of the presentinvention are solid at room temperature, but liquid at body temperatureand, therefore, will melt in the rectum or vaginal cavity and releasethe active (S,S)-glycopyrrolate.

Formulations of the present invention which are suitable for vaginaladministration also include pessaries, tampons, creams, gels, pastes,foams or spray formulations containing such carriers as are known in theart to be appropriate.

Dosage forms for the topical or transdermal administration of(S,S)-glycopyrrolate include powders, sprays, ointments, pastes, creams,lotions, gels, solutions, patches and inhalants. The active compound maybe mixed under sterile conditions with a pharmaceutically acceptablecarrier, and with any preservatives, buffers, or propellants which maybe required.

Formulations of the present invention in the form of ointments, pastes,creams and gels may contain, in addition to (S,S)-glycopyrrolate,excipients, such as animal and vegetable fats, oils, waxes, paraffins,starch, tragacanth, cellulose derivatives, polyethylene glycols,silicones, bentonites, silicic acid, talc and/or zinc oxide, or mixturesthereof.

Powders and sprays may contain, in addition to (S,S)-glycopyrrolate,excipients such as lactose, talc, silicic acid, aluminum hydroxide,calcium silicates and polyamide powder, or mixtures of these substances.Sprays may additionally contain customary propellants, such as, forexample, chlorofluorohydrocarbons, volatile unsubstituted hydrocarbons,hydrocarbon ethers and compressed gases.

Transdermal patches have the added advantage of providing controlleddelivery of the active (S,S)-glycopyrrolate of the present invention tothe body. Such dosage forms may be made by dissolving or dispersing the(S,S)-glycopyrrolate in the proper medium. Absorption enhancers may alsobe used to increase the flux of the (S,S)-glycopyrrolate across theskin. The rate of such flux can be controlled by either providing a ratecontrolling membrane or dispersing the (S,S)-glycopyrrolate in a polymermatrix or gel.

Regardless of the route of administration selected, the pharmaceuticalcompositions of the present invention are formulated intopharmaceutically acceptable dosage forms by conventional methods knownto those of skill in the art. Where necessary, the pharmaceuticalcompositions of the present invention are sterile or can be sterilizedbefore administration to a patient.

In a preferred embodiment, the enantiomerically enriched glycopyrrolatecompositions of the present invention are provided in tablet or capsuleform with, as inactive ingredients, dibasic calcium phosphate, lactose,magnesium stearate, providone and sodium starch glycolate. The capsulesor tablets are preferably formulated with from about 0.25 mg to about250 mg of (S,S)-glycopyrrolate, more preferably with from about 0.50 mgto about 100 mg of (S,S)-glycopyrrolate, and even more preferably withfrom about 1 mg to about 50 mg of (S,S)-glycopyrrolate.

In another preferred embodiment, the enantiomerically enriched(S,S)-glycopyrrolate preparations of the present invention are providedin soft elastic gelatin capsule form. The soft elastic gelatin capsulesare preferably formulated with from about 0.25 mg to about 250 mg of(S,S)-glycopyrrolate, more preferably with from about 0.50 mg to about100 mg of (S,S)-glycopyrrolate, and even more preferably with from about1 mg to about 50 mg of (S,S)-glycopyrrolate.

Actual dosage levels of (S,S)-glycopyrrolate in the pharmaceuticalcompositions of the present invention may be varied so as to obtain anamount of the active ingredient which is effective to achieve thedesired therapeutic response for a particular patient, composition, andmode of administration, without being toxic to the patient.

The selected dosage level and frequency of administration will dependupon a variety of factors including the route of administration, thetime of administration, the rate of excretion of the particular compoundbeing employed, the duration of the treatment, other drugs, compoundsand/or materials used in combination with the (S,S)-glycopyrrolate, theage, sex, weight, condition, general health and prior medical history ofthe patient being treated, and like factors well known in the medicalarts. For example, the dosage regimen is likely to vary with pregnantwomen, nursing mothers and children relative to healthy adults.

A physician having ordinary skill in the art can readily determine andprescribe the effective amount of the pharmaceutical compositionrequired. For example, the physician could start doses of the compoundemployed in the pharmaceutical composition of the present invention atlevels lower than that required in order to achieve the desiredtherapeutic effect and gradually increase the dosage until the desiredeffect is achieved.

A suitable daily dose of (S,S)-glycopyrrolate will be that amount of thecompound which is the lowest dose effective to produce a therapeuticeffect. Such an effective dose will generally depend upon the factorsdescribed above. Generally, the total daily dose of (S,S)-glycopyrrolatefor the conditions described herein may be from about 0.25 mg to about500 mg, more preferably from about 0.50 mg to about 250 mg, and morepreferably from about about 1 mg to about 100 mg.

If desired, the effective daily dose of the active (S,S)-glycopyrrolatemay be administered as two, three, four, five, six or more sub-dosesadministered separately at appropriate intervals throughout the day,optionally, in unit dosage forms.

Another embodiment of the present invention relates to a kit fortreating urinary incontinence, including, e.g., bladder detrusor muscleinstability incontinence, stress incontinence, urge incontinence,overflow incontinence, enuresis, and post-prostectomy incontinence,wherein said kit comprises a pharmaceutical composition comprisingenantiomerically enriched (S,S)-glycopyrrolate, or a pharmaceuticallyacceptable salt thereof, and a pharmaceutically acceptable carrier, andinstructions for administering enantiomerically enriched(S,S)-glycopyrrolate for the treatment of urinary incontinence whilereducing or eliminating anticholinergic adverse effects associated withracemic glycopyrrolate or other incontinence drugs with anticholinergicaction.

The utility of (S,S)-glycopyrrolate may be established by the followingstudies of antimuscarinic, spasmolytic, and calcium entry blockingeffects in models of receptor binding and bladder function.

Binding to Human M₁, M₂, M₃, M₄ and M₅ Muscarinic Receptor Subtypes

These experiments are carried out on membranes prepared from SF9 cellsinfected with baculovirus to express the human recombinant M₁, M₂, M₃,M₄, and M₅ muscarinic receptor subtypes. The binding assays areperformed as set forth in Table

                                      TABLE 1                                     __________________________________________________________________________                            Incubation                                                                            Reference                                       Receptor Radioligand Conc. nonspecific time/temp. Compound                  __________________________________________________________________________    M.sub.1H                                                                            [.sup.3 H]piren.sup.zepine                                                             2 nM                                                                             atropine                                                                            60 min/27° C.                                                                  pirenzepine                                        (1 μM)                                                                  M.sub.2H [.sup.3 H]AF-D.sup.X 384   2 nM atropine 60 min/27° C.                                      methoctramine                                      (1 μM)                                                                  M.sub.3H [.sup.3 H]4-.sup.DAMP 0.8 nM atropine 60 min/27° C.                                         4-DAMP                                             (1 μM)                                                                  M.sub.4H [.sup.3 H]4-.sup.DAMP 0.3 nM atropine 60 min/27° C.                                         4-DAMP                                             (1 μM)                                                                  M.sub.5H [.sup.3 H]4-.sup.DAMP 0.5 nM atropine 60 min/27° C.                                         4-DAMP                                             (1 μM)                                                                __________________________________________________________________________

Following incubation, the assays are rapidly filtered under vacuumthrough GF/B glass fiber filters (available, e.g., from Whatman) andwashed with an ice-cold buffer using a Brandel Cell Harvester. Boundradioactivity is determined with a liquid scintillation counter (e.g.,LS 6000, Beckman) using a liquid scintillation cocktail (e.g., Formula99, DuPont NEN).

The compounds are tested on each receptor at 10 concentrations induplicate to obtain competition curves. In each experiment, thereference compound for the receptor under investigation issimultaneously tested at 8 concentrations in duplicate to obtain acompetition curve in order to validate this experiment.

The specific radioligand binding of each receptor is defined as thedifference between total binding and nonspecific binding determined inthe presence of an excess of unlabelled ligand. IC₅₀ values(concentrations required to inhibit 50% of specific binding) aredetermined by non linear regression analysis of the competition curves.These parameters are obtained by curve fitting using Sigmaplot™software.

Binding to Calcium Channels

Binding assays are performed using the methods set forth in Table

                  TABLE 2                                                         ______________________________________                                                               Reference                                                Receptors Membranes Compounds References                                    ______________________________________                                        Ca channel  rat cerebral                                                                             diltiazem Schoemaker and                                 (T + L, diltiazem site) cortex  Langer (1985)                                 Ca channel rat cerebral D600 Reynolds et al                                   (T + L, verapamil site) cortex  (1986)                                      ______________________________________                                    

The experiment conditions are set forth in Table

                  TABLE 3                                                         ______________________________________                                                               Concen-         Incu-                                    Receptors Ligands trations Nonspecific bation                               ______________________________________                                        Ca channel  [.sup.3 H] diltiazem                                                                       5 nM  dilitiazem                                                                            120 min                                  (T + L, diltiazem site)   (10 μM) 25° C.                            Ca channel [.sup.3 H]D.sup.888 0.5 nM D 600 60 min                            (T + L, verapamil site)   (10 μM) 22° C.                          ______________________________________                                    

Following incubation, the assays are rapidly filtered under vacuumthrough GF/B or GF/C glass fiber filters (available, e.g., from Whatman)and washed with an ice-cold buffer using a Brandel Cell Harvester. Boundradio-activity is determined with a liquid scintillation counter (e.g.,LS 6000, Beckman) using a liquid scintillation cocktail (e.g., Formula989, DuPont NEN).

The compounds are tested in duplicate on each receptor at aconcentration of 10⁻⁵ M. In each experiment, the reference compound forthe receptor under investigation is simultaneously tested at 8concentrations in duplicate to obtain a competition curve in order tovalidate this experiment.

The specific radioligand binding of each receptor is defined as thedifference between total binding and nonspecific binding determined inthe presence of an excess of unlabelled ligand. Mean values areexpressed as a percentage of inhibition of specific binding. IC₅₀ values(concentration required to inhibit 50% of specific binding) aredetermined by non linear regression analysis of their competitioncurves. These parameters are obtained by curve fitting using Sigmaplot™software.

Functional Characterization of Antimuscarinic/Antispasmodic Activity

The effects of (S,S)-glycopyrrolate are studied in an in vitro model ofbladder function. For example, isolated strips of guinea pig bladdersmooth muscle are mounted in a tissue bath and contracted either withthe muscarinic agonist carbachol or with increasing concentrations ofexternal potassium.

Bladder Strips

Experiments are performed using methods similar to those described byKachur et al. (J. Pharmacol. Exp. Ther., 247:867-872 (1988)) andNoronha-Blob and Kachur (J. Pharmacol. Exp. Ther., 256:562-567 (1991)).Strips of tissue (approximately 10 mm long and 1.5 mm wide) are removedfrom the body of the urinary bladder of male guinea pigs weighing400-600 g. (available, e.g., from Elm Hill Breeding Laboratories,Chelmsford, Mass.). The tissues are suspended in an oxygenated buffer ofthe following composition, in mM: NaCl, 133; KCl, 4.7; CaCl₂, 2.5;MgSO₄, 0.6; NaH₂ PO₄, 1.3; NaHCO₃, 16.3; and glucose, 7.7. The tissuesare maintained at 37.5° C. Isometric contractions of the tissues arerecorded by using appropriate transducers and an ink-writing polygraph.A resting tension of 0.5 grams is maintained on each tissue at alltimes.

Individual tissues are allowed to equilibrate with the bathing solutionfor one hour before proceeding with the experiment.

Carbachol-induced Contractions

These series of experiments focus on anticholinergic actions. In theseexperiments, in order to assess the viability of each tissue and toserve as a frame of reference, the contractions of each strip of tissueare recorded initially in response to exposure to a tissue medium inwhich the NaCl is replaced by KCl to yield a concentration of 137.7 mMKCl in the medium. This is followed by return to the standard medium,and then by exposure to progressively increasing concentrations ofcarbachol, with separate exposure to each concentration only until thepeak response has been recorded.

Then, leaving one strip untreated and/or one strip exposed to thevehicle to serve as control tissue(s), the remaining strips each areexposed for one hour to one concentration of a test substance. Thevehicle controls are used when, because of poor solubility, stocksolutions the test substances are prepared in a vehicle, e.g., ethanol.Finally, the responses to increasing concentrations of carbacholfollowed by exposure to 137.7 mM KCl are recorded a second time.

Potassium-induced Contractions

These experiments focus on the spasmolytic action of the substancesbeing studied. Contractions are recorded in response to sequentiallyincreasing the concentration of potassium in the medium.

To determine whether test substances decrease the peak response toagonists, the peak tension developed by each strip during the second setof determinations is expressed as a percent of the peak tensiondeveloped during the first concentration-effect determination. Then, foreach test substance the resultant data are analyzed fortreatment-related differences by one-way analysis of variance (ANOVA).Since only one concentration of test substance is studied in each stripof bladder, the procedures of Arunlakshana and Schild (1959) are used inmodified form to estimate the pA2 and slope of the Schild regression.

First, the concentrations of agonist producing a half-maximal response(the EC₅₀) is estimated for each strip from the second set ofconcentration-effect data. The EC₅₀ is obtained from linear regressionlines fit to the logarithm of the concentration of drug and theresponses bracketing the half maximum level of response. For eachdrug-treated strip, a "concentration ratio" (CR) is calculated as theratio of the EC₅₀ of the treated tissue divided by the EC₅₀ of theuntreated tissue. For each experiment where two or more strips areexposed to the same test substance but at different concentrations, thelogarithm of this ratio minus one [i.e., log (CR-1)] is plotted againstthe logarithm of the concentration of antagonist to which the strip hadbeen exposed to produce "Schild plots". A regression analysis relatinglog(CR-1) to the logarithm of the concentration of the antagonist isemployed to estimate the pA2 and the slope of the regression line.

Finally, experiments are grouped by test substance and the mean ±S.E. ofthe pA2 and slope are calculated. The 95% confidence limits (CL) for theslope are estimated from its S.E. using standard methods. Forexperiments in which only one strip is exposed to a given testsubstance, a pKD is calculated as (concentration of antagonist)/(CR-1)and the negative logarithm of the KD is then pooled with the pA2 valuesto yield an expanded set of pA2 values.

The embodiments of the present invention described above are intended tobe merely exemplary and those skilled in the art will recognize, or beable to ascertain using no more than routine experimentation, numerousequivalents to the specific procedures described herein. All suchequivalents are considered to be within the scope of the presentinvention and are covered by the following claims.

The contents of all references described herein are hereby incorporatedby reference.

Other embodiments are within the following claims.

What is claimed is:
 1. Enantiomerically enriched (S,S)-glycopyrrolate,or a pharmaceutically acceptable salt thereof.
 2. (S,S)-glycopyrrolate,or a pharmaceutically acceptable salt thereof, substantially free of(R,R)-glycopyrrolate.
 3. A pharmaceutical composition, comprisingenantiomerically enriched (S,S)-glycopyrrolate, or a pharmaceuticallyacceptable salt thereof, and a pharmaceutically acceptable carrier. 4.The pharmaceutical composition as recited in claim 3, wherein(S,S)-glycopyrrolate comprises greater than 50% by weight of the totalglycopyrrolate in said pharmaceutical composition.
 5. The pharmaceuticalcomposition as recited in claim 4, wherein (S,S)-glycopyrrolatecomprises at least 80% by weight of the total glycopyrrolate in saidpharmaceutical composition.
 6. The pharmaceutical composition as recitedin claim 3, wherein said pharmaceutical composition is formulated fororal administration, for administration by injection, or foradministration by intravesical perfusion.
 7. The pharmaceuticalcomposition as recited in claim 3, wherein the amount of(S,S)-glycopyrrolate present in said pharmaceutical composition is about0.25 mg to about 500 mg.
 8. The pharmaceutical composition as recited inclaim 7, wherein the amount of (S,S)-glycopyrrolate present in saidpharmaceutical composition is from about 1 mg to about 100 mg.
 9. Thepharmaceutical composition as recited in claim 3, whereinenantiomerically enriched (S,S)-glycopyrrolate comprises from about 1%to about 99% of the total pharmaceutical composition.
 10. Thepharmaceutical composition as recited in claim 9, whereinenantiomerically enriched (S,S)-glycopyrrolate comprises from about 10%to about 30% of the total pharmaceutical composition.
 11. Apharmaceutical composition, comprising (S,S)-glycopyrrolate, or apharmaceutically acceptable salt thereof, substantially free of(R,R)-glycopyrrolate, and a pharmaceutically acceptable carrier.
 12. Thepharmaceutical composition as recited in claim 11, wherein(S,S)-glycopyrrolate comprises at least 85% by weight of the totalglycopyrrolate in said pharmaceutical composition.
 13. Thepharmaceutical composition as recited in claim 12, wherein(S,S)-glycopyrrolate comprises at least 99% by weight of the totalglycopyrrolate in said pharmaceutical composition.
 14. Thepharmaceutical composition as recited in claim 11, wherein saidpharmaceutical composition is formulated for oral administration, foradministration by injection, or for administration by intravesicalperfusion.
 15. The pharmaceutical composition as recited in claim 11,wherein the amount of (S,S)-glycopyrrolate present in saidpharmaceutical composition is about 0.25 mg to about 500 mg.
 16. Thepharmaceutical composition as recited in claim 15, wherein the amount of(S,S)-glycopyrrolate present in said pharmaceutical composition is fromabout 1 mg to about 100 mg.
 17. The pharmaceutical composition asrecited in claim 11, wherein substantially enantiomerically enriched(S,S)-glycopyrrolate comprises from about 1% to about 99% of the totalpharmaceutical composition.
 18. The pharmaceutical composition asrecited in claim 17, wherein substantially enantiomerically enriched(S,S)-glycopyrrolate comprises from about 10% to about 30% of the totalpharmaceutical composition.
 19. A pharmaceutical unit dosage form, whichcomprises enantiomerically enriched (S,S)-glycopyrrolate, or apharmaceutically acceptable salt thereof, and a pharmaceutical carrier,wherein said pharmaceutical unit dosage form is a tablet.
 20. Thepharmaceutical unit dosage form as recited in claim 19, wherein saidenantiomerically enriched (S,S)-glycopyrrolate is present in an amountof about 0.25 mg to about 250 mg.
 21. The pharmaceutical unit dosageform as recited in claim 20, wherein said enantiomerically enriched(S,S)-glycopyrrolate is present in an amount of about 1 mg to about 50mg.
 22. A pharmaceutical unit dosage form which comprises substantiallyenantiomerically enriched (S,S)-glycopyrrolate, or a pharmaceuticallyacceptable salt thereof, and a pharmaceutical carrier, wherein saidpharmaceutical unit dosage form is a tablet.
 23. A pharmaceutical unitdosage form, which comprises enantiomerically enriched(S,S)-glycopyrrolate, or a pharmaceutically acceptable salt thereof, anda pharmaceutical carrier, wherein said pharmaceutical unit dosage formis a soft elastic gelatin capsule.
 24. The pharmaceutical unit dosageform as recited in claim 23, wherein said enantiomerically enriched(S,S)-glycopyrrolate is present in an amount of about 0.25 mg to about250 mg.
 25. The pharmaceutical unit dosage for as recited in claim 24,wherein said enantiomerically enriched (S,S)-glycopyrrolate is presentin an amount of about 1 mg to about 50 mg.
 26. A pharmaceutical unitdosage form which comprises substantially enantiomerically enriched(S,S)-glycopyrrolate, or a pharmaceutically acceptable salt thereof, anda pharmaceutical carrier, wherein said pharmaceutical unit dosage formis a soft elastic gelatin capsule.
 27. A kit for treating urinaryincontinence, wherein said kit comprises a pharmaceutical compositioncomprising enantiomerically enriched (S,S)-glycopyrrolate, or apharmaceutically acceptable salt thereof, and a pharmaceuticallyacceptable carrier, and instructions for administering enantiomericallyenriched (S,S)-glycopyrrolate for the treatment of urinary incontinencewhile reducing or eliminating concomitant liability of adverse effect.28. The kit as recited in claim 27, wherein said adverse effect is oneor more of drowsiness, epistaxis, xerostomia, mydriasis, cycloplegia,cardiovascular tachycardia, cardiovascular palpitations, increasedocular pressure, nausea, constipation, decreased sweating, impotence, orunwanted dermal manifestations.
 29. A kit for treating urinaryincontinence, wherein said kit comprises a pharmaceutical compositioncomprising substantially enantiomerically enriched (S,S)-glycopyrrolate,or a pharmaceutically acceptable salt thereof, and a pharmaceuticallyacceptable carrier, and instructions for administering substantiallyenantiomerically enriched (S,S)-glycopyrrolate for the treatment ofurinary incontinence while reducing or eliminating concomitant liabilityof adverse effects.
 30. The kit as recited in claim 28 wherein saidadverse effect is one or more of drowsiness, epistaxis, xerostomia,mydriasis, cycloplegia, cardiovascular tachycardia, cardiovascularpalpitations, increased ocular pressure, nausea, constipation, decreasedsweating, impotence, or unwanted dermal manifestations.
 31. A method fortreating urinary incontinence, comprising administering to a subject inneed thereof a therapeutically effective amount of enantiomericallyenriched (S,S)-glycopyrrolate, or a pharmaceutically acceptable saltthereof.
 32. The method as recited in claim 1, wherein theenantiomerically enriched (S,S)-glycopyrrolate, or a pharmaceuticallyacceptable salt thereof, is administered as a pharmaceutical compositioncomprising said enantiomerically enriched (S,S)-glycopyrrolate, or apharmaceutically acceptable salt thereof, and a pharmaceuticallyacceptable carrier.
 33. The method as recited in claim 2, wherein saidpharmaceutical composition is administered by oral, parenteral,transdermal, rectal, or vaginal administration.
 34. The method asrecited in claim 32, wherein said pharmaceutical composition isadministered by injection or intravesical perfusion.
 35. The method asrecited in claim 1, wherein a daily amount of (S,S)-glycopyrrolateadministered in the preparation is about 0.25 mg to about 500 mg. 36.The method as recited in claim 35, wherein the daily amount of(S,S)-glycopyrrolate administered in the preparation is about 1 mg toabout 100 mg.
 37. The method as recited in claim 32, wherein(S,S)-glycopyrrolate comprises greater than 50% by weight of the totalglycopyrrolate in said pharmaceutical composition.
 38. The method asrecited in claim 37, wherein (S,S)-glycopyrrolate comprises at least 80%by weight of the total glycopyrrolate in said pharmaceuticalcomposition.
 39. The method as recited in claim 31, wherein(S,S)-glycopyrrolate is administered as a pharmaceutical compositioncomprising substantially enantiomerically enriched (S,S)-glycopyrrolate,or a pharmaceutically acceptable salt thereof, and a pharmaceuticallyacceptable carrier.
 40. The method as recited in claim 39, wherein(S,S)-glycopyrrolate comprises at least 85% by weight of the totalglycopyrrolate in said pharmaceutical composition.
 41. The method asrecited in claim 40, wherein (S,S)-glycopyrrolate comprises at least 99%by weight of the total glycopyrrolate in said pharmaceuticalcomposition.
 42. The method as recited in claim 31, wherein the subjectis treated for stress incontinence, urge incontinence, post-prostectomyincontinence, or enuresis.
 43. A method for treating bladder detrusormuscle instability, said method comprising administering to a subject inneed thereof a therapeutically effective amount of enantiomericallyenriched (S,S)-glycopyrrolate, or a pharmaceutically acceptable saltthereof.
 44. The method as recited in claim 23, wherein saidenantiomerically enriched (S,S)-glycopyrrolate, or a pharmaceuticallyacceptable salt thereof, is substantially free of (R,R)-glycopyrrolate.